JAMA Psychiatry Weighs In: The “Ketamine for Depression” Buzz

JAMA: “Ketamine for Depression” Buzz

The mental health community is all a-buzz about IV ketamine for treating depression and other psychiatric disorders, and for good reason. For the first time, people who’ve been treated without success for years are experiencing relief and enjoying their lives.

For anyone who has suffered from psychiatric disorders without relief for a prolonged time, the possibility of a breakthrough treatment that actually works can mean the difference between life or death. Or utter misery vs. hope. Most folks would go for hope … wouldn’t you?

This anesthetic-turned-street-drug has returned to the scene to restore its reputation by providing a remarkably successful, and fast, reversal of depression in patients who’ve not experienced relief in a very long time– some of them for decades.

In addition, these infusions in single doses or in a series of doses, reverse suicidal thinking, often within hours, if not before the IV infusion is even completed. Now that’s lifesaving. 

What’s more, suicidal thoughts disappear immediately in many cases, whether the depression is relieved or not.

So yes, some of us in the psychiatry community are excited about what IV ketamine can do.

Psychiatrists Containing Enthusiasm

But … we know we have to contain ourselves, and maintain a scientific approach to this “off-label” use of the anesthetic ketamine. So we read the research, keep up with the published studies, and pore over the data to be sure our enthusiasm doesn’t get ahead of us.

We talk to each other endlessly, scour the journals, go to conferences, stay up late, stay at the office late, pull together every shred of published research, every letter to the editor, every blog and YouTube video.

Then, we watch TED talks. And we tweet, we message, we write. And we see dozens of people every day who are depressed. Sick of it. Suicidal.  We offer many treatments.  And we offer hope.  Some of us offer off-label treatment with IV ketamine.  And some of us have seen hundreds of ketamine patients, and administered nearly 1000 infusions.  (That’s us.)  We’re in the trenches.  Deep.

Now comes this timely release to further illuminate the path for psychiatrists who are moving forward to help their patients with this breakthrough treatment.

So what does the APA (American Psychiatric Association) and JAMA Psychiatry (Journal of the American Medical Association Psychiatry) have to say about this unexpected surprise that treats psychiatric disorders?

In the March 1, 2017 issue of JAMA Psychiatry online, a consensus statement was released by the American Psychiatric Association (APA) Council of Research Task Force on Novel Biomarkers and Treatments regarding the off-label use of ketamine in the treatment of mood and other psychiatric disorders.  The best and brightest are on that Task Force.

The Task Force made the point that there is compelling evidence that IV ketamine has the ability to provide rapid and robust antidepressant effects in patients with mood disorders who had previously displayed resistance to treatment.

Limited “Ketamine for Depression” Data

They acknowledged the sample sizes were small in these studies. And use of low dose ketamine for psychiatric disorders has increased at such a rapid rate that there’s a lot we still don’t know.

So, one point they made is that there’s limited data.  The strongest data about the use of ketamine in the treatment of psychiatric disorders is for the treatment of major depressive episodes where there are no psychotic features.

Their concern was that even in the case of major depression, some of data that was evaluated had been collected from only the first week following one dose of ketamine treatment.

Again, limited studies, limited number of patients, limited information about outcomes, side effects, impact of long-term use.

Still, we know that anesthesiologists have been using this drug for decades and have found it to be quite safe in controlled settings. But the APA Task Force’s statement isn’t intended to decrease the use of ketamine in treating psychiatric disorders. But instead to highlight where we are and the most critical things to consider for keeping its use safe while research on ketamine proceeds.

Criteria for Ketamine Treatment

So, initially, the Consensus Statement recommends we take several steps when we see a patient to help determine if ketamine treatment might be appropriate for him or her.  They include: 

• Performing a comprehensive evaluation to determine that the patient meets appropriate diagnostic criteria for depression
• Ensuring the patient has completed adequate courses of FDA-approved antidepressants before considering ketamine
• Thoroughly reviewing the psychiatric and medical history as well as the patient’s potential risk factors for ketamine treatment
• Carefully evaluating any history of substance abuse, including baseline urine toxicology screens

In addition, they said the physician should thoroughly discuss ketamine treatment with the patient before use. The possible benefits of it, as well as the possible risks associated with its use for any given patient. This empowers the patient to make a truly informed decision about whether the benefits are greater than the risks. Of course — that makes sense.  It’s the very basis of collaborative treatment in medicine and the basis of informed consent. Then, like with any medical procedure, we should obtain written consent before beginning the infusion.

Precautions with Ketamine

Next, in terms of specifics, spikes in blood pressure sometimes occur with ketamine infusions, so patients receiving ketamine therapy ought to be in a facility setting where we can manage any unexpected medical incident.

Even so, ketamine is considered “reasonably safe” at the recommended dosage of 0.5mg/kg over 40 minutes.

Because of ketamine’s natural action, patients experience dissociative effects that should pass momentarily. Or some may have short-lived vivid experiences of heightened perceptions, or intense ideas or memories.  

Understandably, patients who experience effects like this may react with behaviors unlike their usual personality. So, physicians must be prepared to treat episodes of that nature. Which is why we want to see ketamine administered in specially prepared clinical settings, instead of at home.

Suicide Prevention

Also, as effective as ketamine is with suicidal thinking, there’s still the risk that the self-destructive thoughts or plans won’t lift for some patients. So it’s vital that physicians evaluate their patients after ketamine treatment before discharging them home.

Overall, psychiatrists must form a comprehensive plan for managing the patient’s depression along with needed followups. Ketamine is a highly effective drug to be incorporated into the overall treatment and management of depression.

The APA Task Force strongly advised that psychiatrists develop a standard operating procedure for administration of ketamine.

At the very minimum, it should incorporate these points:

• Signed informed consent and pre-procedure evaluation
• Baseline assessment of vital signs: blood pressure, heart rate, O2 saturation
• Continual evaluation of patient’s mental and physiologic status throughout the infusion
• Management of side effects that may occur during the treatment

Studies are lacking to evaluate the efficacy of long-term use of ketamine treatment for depression.

The most useful data to date indicate that infusions given up to twice a week and within four weeks are effective.  Patients should be monitored with a rating instrument to assess changes in mood.

Avoid Abuse or Dependence

The Task Force also recommends that dosing of ketamine be discontinued if infusions can’t be reduced to one per week.

The committee members agreed that ketamine is an incredibly promising treatment but must be used with standards that ensure the highest level of safety.

Ketamine is the most abused drug in Asia. So the widespread use of it in the US – for therapeutic purposes – must be surrounded in safeguards to avoid the advent of abuse or dependence, in spite of its benefits.

JAMA: Ketamine for Depression – The Buzz

All in all, the buzz is that ketamine is the most promising new treatment to date for depression. The data is limited, it’s true. There’s much to be explored. But, we’re working rapidly to pull together all of the available evidence and all of the best practice recommendations as we proceed. This treatment is bringing hope where there was very little before.

We’re thrilled to be on the forefront, and we’ve developed our protocols for IV ketamine very carefully. Not only to set the bar for the standard of practice in our field but to exceed the standard.

At Innovative Psychiatry, our protocols comply with the recommendations of APA Council of Research Task Force on Novel Biomarkers and Treatments published in JAMA Psychiatry. But, we go above and beyond those. We educate you. Then, provide you with the research articles that we read ourselves. And ensure that we offer IV ketamine infusions as a psychiatric treatment — not simply as a medical procedure.  

To that end, we work with you and your physicians and therapists for the best possible results.  And we pull out every stop to help you feel better and enjoy life again when nothing else has helped.

Call for an appointment, and let’s work together to help you rediscover your best self.

To your emerging best self,

Lori Calabrese, MD